Through October 4, Weekly Report will profile the nominees for this year’s Community Health Leadership Award, which will be given out at the Annual Meeting October 11 in Seattle. Learn more about the award.
Summit Pacific Medical Center in Elma has developed a robust care coordination program that has flourished during the last five years, serving patients as part of the medical center’s volume-to-value efforts. The coordination program consists of health coaching, chronic disease management, transitional care management and advance care planning.
Health coaching and motivational interviewing have proven key to engaging patients in their own health care and creating positive change by identifying areas of strength. Chronic disease management allows their registered nurses the to work as part of the primary care team, with RN care coordinators serving as daily advocates for patients and bridging the gap between primary care visits by actively working with patients to manage their own chronic diseases. Transitional care management ensures that notice of emergency department visits or inpatient admissions are relayed back to a patient’s primary care provider.
Continuity of care and medication management have proven essential to avoiding hospital readmissions. The RN care coordinator ensures the components of care are in place regardless of where the patient receives that care within the health system. Once only serving those patients with two or more chronic medical conditions, care coordination has been expanded to all. Extending this expert resource to those at risk of chronic co-morbidities, or to those who are particularly vulnerable — like children and pregnant mothers — ensures that care coordination efforts reach patients at all stages of life.
The results have been significant when a patient has shown engagement and worked closely with the RN care coordinator. There has been a dramatic reduction in hospital readmissions. ER utilization has decreased. Medicare wellness visits have encouraged patients to receive preventive health exams when they might not have otherwise. Patients who have followed through with preventive exams have been diagnosed with early stages of cancer, increasing chances of survival. Lastly, by integrating behavioral and primary health, patients have had improved access to care and improved outcomes with their physical, mental health and social needs.
Many health care organizations and regulatory bodies — including the Centers for Disease Control and Prevention — recommend that all hospitals, regardless of size, institute antimicrobial stewardship programs to foster appropriate use of antibiotics and prevent the spread of drug-resistant illnesses. For many small or rural hospitals, it can be a challenge to assemble this expertise in house. To assist these facilities, the University of Washington launched a tele-antimicrobial stewardship program to share its expertise.
The program, launched in 2017, uses innovative communications technologies to connect professionals from 30 hospitals across the state to UW’s experts. The core of the program is a weekly hour-long virtual meeting, which includes a brief didactic and discussion of submitted cases. The program’s website is also a rich source of information, and the expert panel is available outside of the weekly meetings for more urgent questions.
Half of Washington’s critical access hospitals now participate, and the program has improved access to experts on infectious diseases and standardized care pathways, order sets and antimicrobial formularies. The program also offers community and continuing education for participants. (Tim Pfarr)